Inspection on 21/11/05 for Granville House

This inspection was carried out on 21st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Granville House 17/09/09

Granville House 11/08/09

Granville House 18/10/07

Granville House 16/02/07

Granville House 26/04/05

Granville House 19/01/05

Granville House 01/06/04

Granville House 02/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Granville House 40 Woodgreen Road Wednesbury West Midlands WS10 9QS Lead Inspector Mr Jon Potts Unannounced Inspection 21st November 2005 1:40pm X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Granville House Address 40 Woodgreen Road Wednesbury West Midlands WS10 9QS Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 502 2654 0121 502 2654 Mr Avtar Singh Sandhu Mrs Amarjit Kaur Sandhu Wendy Trainer Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26/4/05 Brief Description of the Service: The home is an adapted and extended traditional detached property that is sited within a short distance of Wednesbury Town centre with access to good transport links and the M6 motorway. Accommodation in the home includes three lounges, dining area with toilets and bathrooms on every floor. There are 14 single and 3 shared rooms, these on three floors, with only the first floor accessible via shaft lift. There is parking to the front and rear of the home and a patio and small garden area to the side and rear. There are a numbers of aids available including adapted baths, raised toilet seats and call system. The home is run by a registered manager who oversees a number of staff including seniors and carers. There are also some ancillary staff in place including cook, domestic and handyman. The home provides a service to older people without complex needs and whilst nursing maybe provided by primary health care staff on occassions (such as district nurses) the home does not itself offer any nursing care. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 1.40pm and concluded at 7.10pm. Evidence was drawn from some case tracking including discussion with two residents. Documents sampled (as well as residents case files) included some policies/procedures, training records, records of fees for residency, health and safety documentation and some staff records. There was also discussion with two social workers and management. Residents and staff are to be thanked for their assistance with the inspection. What the service does well: What has improved since the last inspection? What they could do better: The management need to ensure that residents are given the option of care plans in appropriate formats if wanted and that there is clear evidence of their involvement with care planning. There was a need to review the nutritional assessment for one identified resident due to weight loss. Where residents do Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 6 not wish to see dentist or similar this choice must be clearly documented. Work on the homes quality assurance system needs to be continued and a business plan developed (that can be combined with an annual development plan in the future). The homes charter of rights checklist would benefit from some minor amendment and relatives should be given a copy of the homes policy on maintaining their involvement on a resident’s admission to the home. The only identified overall training need was in respect of bereavement/working with the dying, which the manager stated is planned. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents’ needs are assessed prior to their admission to the home, with assurance given that the home is able to meet these needs following the assessment. EVIDENCE: From sight of pre admission assessments for one resident it was evident that the documentation and actual process of assessing prospective residents has improved. The home carries out its own assessment in tandem with the social worker’s assessment and there was clear documentary evidence of this process being instrumental in the manager’s/staff decision as to whether the home was able to met the prospective residents needs. The manager has introduced a ‘this is my life’ booklet which assist with gathering information about the individual, this building on the information within the homes assessments. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 The resident’s health, personal and social care needs are set out in plans of care. Evidence of resident’s involvement in drawing up these plans could be better. Resident’s health care needs are promoted by the home. EVIDENCE: Case tracking two residents care evidenced that the documented plans were consistent with the evidence that was drawn from other sources, including discussion with the appropriate resident. One of the residents was clear that they had no interest in seeing their care plan but there needs to be clear documentary evidence of the residents (or their representatives) involvement in the care planning process, with care plans provided in appropriate formats if so requested (for example given verbally by staff, in larger print etc). The plans tracked were however consistent with the views and experiences of the residents spoken to. The inspector discussed the manager’s proposals in respect of planned training for the staff in care planning. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 10 Resident’s access to health care services was found to be well documented although the manager was advised to ensure that where residents express a wish not to access a particular service (such as the dentist) that this choice is clearly documented. Risk assessments were available in regard to falls, tissue viability, nutrition, moving and handling. There was a nutritional assessment that required urgent review however due to a residents significant weight loss. The manager was aware of this but was advised that action taken, or due to be taken must be documented. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 Contact with family/friends/representatives by residents is supported by the staff team. Written guidance issued by the home is not currently given to relatives on a resident’s admission. Residents are encouraged to exercise choice and control over their lives. EVIDENCE: The home was seen to have a policy on visiting and maintaining relatives involvement although this as yet is not given to relatives when the resident is first admitted as should be the case. There is no restriction on visiting times and if privacy is required by the resident when seeing their relatives this is available as is hospitality in the forms of offered drinks (as confirmed by one resident). Where there maybe restrictions on access by relatives these were seen to be agreed on an individual basis, with discussion with the resident and other professionals as may be appropriate. If there are restrictions these do need to be clearly documented however. From discussion with residents and sight of documented checklists it was evident that residents are encouraged to exercise choice and control over their lives. One resident spoke of being able to access a postal vote for elections, as Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 12 was their choice, and both residents spoken to were aware of the right to access their records, although neither had any interest in doing so. The manager was advised to expand the charter of rights checklist in the resident’s case files to include a section on access to records (in accordance with Data Protection) and choices around voting. There was clear evidence on the day of the inspection of one resident having access to an advocate and information was available to other residents within the home. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17, 18 Residents are protected from abuse and their legal rights protected. EVIDENCE: There is recent evidence of the home having identified and reported an incident of abuse appropriately, this leading to instigation of the local authorities vulnerable adults procedures. Discussion with a social worker evidenced that the home had maintained excellent communication with him throughout the investigation and was reassured as to safety of the service based on this experience. The home was seen to have appropriate procedures in place in respect of adult protection and all staff have received training and are now due an update. The manager and the representative of the provider were very clear about their responsibilities in respect of reporting any abuse. Both residents spoken to were very clear that they felt ‘safe’ living at Granville house. A copy of an enhanced disclosure, or evidence that one has been obtained was seen for every member of staff. For more recently employed staff there was evidence that they had been checked against the POVA (Protection of Vulnerable adults) list. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,26 Residents live in a comfortable and well-maintained environment that is clean, pleasant and hygienic. EVIDENCE: There was seen to have been a significant improvement in the standard of the physical environment since the last inspection of the home, this evidence of some significant expenditure. The home now presents as far cleaner, lighter and more comfortable. This improvement was achieved through redecoration of many areas and some enhanced lighting. In addition the following has been purchased or carried out: Painting of the home’s exterior, Provision of a concrete access ramp, Adaption of the homes calls system so the alarm cannot now be cancelled on the main control panel, Purchase of a new commercial washing machine. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 15 There was no evidence of any malodours at any time during the course of the inspection and fixed paper towel and liquid soap dispensers were seen to be available in toilets. Discussion with one resident who was in a shared room indicated that there were some concerns about a new resident moving in with her. The manager must ensure that any resident that chooses to share a room with this resident meets them prior to admission and they have chance to get to know each other, and discuss sharing the bedroom, so that they can both decide whether this is acceptable to them. The manager was clearly aware of this issue when the inspector raised it. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,30 Residents are cared for safely and appropriately. Overall, the staff group is well trained and competent to carry out their work. EVIDENCE: There are currently fifteen care staff, nine of which currently hold an NVQ level 2 qualification, this over the 50 required. Comment from residents indicated that the residents are in ‘safe’ hands. The home has a training plan that showed that the staff team as a whole has training in a variety of areas although there is an identified need for bereavement training, this stated by the manager to be planned. The majority of staff have received training in mandatory areas such as first aid, moving and handling, health and safety etc. Six staff have completed infection control and a further two are undertaking this training. New staff have access to an appropriate induction procedure although the manager is currently in the process of revising this to fit in with the revised standards issued by skills for care recently. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34 Residents live in a home that is run and managed by a person, fit to be in charge, of good character and able to discharge their responsibilities fully. The home is run in the best interest of the residents, with the management developing ways in which to better evidence that this is the case. The way in which the home safeguards residents needs to be presented in a clear business plan for the home. EVIDENCE: The home’s manager has since the time of the last inspection completed their registration, the outcome that they were assessed as ‘fit’ to manage the home. The evidence drawn from discussion with the manager, overall outcomes and Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 18 sight of various documentation showed that the manager was discharging her responsibilities appropriately. Whilst the home has not yet a fully operational quality assurance system up and running discussion with the provider’s representative and manager centred around training they were currently completing with a training provider in respect of implementing a quality assurance programme. The inspector saw some evidence of the home beginning to introduce document control and there are systems in place for consultation with residents and stakeholders. Discussion with the trainer indicated that the training would be completed around the end of the year at which point the manager would be in a position to draw up an audit schedule for the forthcoming year. The provider has to date not completed (although is working on) the home’s business plan, and this is the only requirement from the last inspection that remains unmet. A copy of this plan is to be submitted to the CSCI without delay. The provider’s representative was advised that the development of the homes annual development plan could be tied in with reviews and up dates of the homes business plan. Outcomes from this inspection do however indicate that the home is overall run in the resident’s best interests and the development of a worthwhile quality system will allow the manager to better evidence this, as well as becoming more proactive in respect of issues that arise. Whilst the standard on residents financial interest was not fully assessed the home now has a clear record of all fees received in respect of residency fees from residents or their relatives. Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 2 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 3 X X X 2 X X 3 STAFFING Standard No Score 27 X 28 4 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 2 X X X X Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12, 15 Requirement Timescale for action 31/01/06 2 OP8 3 4 OP33 OP34 There must be clear evidence of the home having consulted with the resident or their chosen representative in respect of their individual care plan. Plans must be signed to show involvement or if they do not wish to be involved this choice clearly documented. If residents require amended care plan formats to allow their involvement (i.e. audio, large print etc) this must be actioned. 13, 14 The nutritional assessment for resident FB must be reviewed and updated in light of the current actions staff are taking. 24 To continue developing the homes quality assurance system as discussed. 24, 25, 32 To produce a business and financial plan, a copy to be sent to the CSCI. This plan should take into account planned and costed changes and be reviewed annually. The initial date for meeting this requirement was the 19.3.05. 15/12/05 31/03/06 15/12/05 Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP8 OP13 OP13 OP17 OP23 Good Practice Recommendations Where residents express a clear wish not to access dental services this should be clearly documented in their case file. Resident’s relatives/friends/representatives should be given a copy of the homes policy on their involvement at the point of the admission of the former. An agreed restrictions on visiting as agreed with a resident or other representative must be clearly documented. The home’s charter of rights checklist should be expanded to include a section on access to records and choices re voting. Resident FB should be allowed to meet any resident that may possibly share the bedroom with them prior to moving in, this to see if both parties are agreeable to this arrangement. To provide staff with training in working with death and bereavement as planned. 6 OP30 Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Granville House DS0000004857.V267033.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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